KPC Biotech Molecular Laboratory
1117 E Devonshire Ave, Hemet, CA 92543
CLIA#: 05D2227042
Fax: (951) 765-4829
Tel: (800) 249-9478
SEXUALLY TRANSMITTED INFECTION
TEST REQUISITION FORM
Patient Information
Billing Information
Billing Information
Specimen Information
Patient Name:
Date of Birth: ___ / ___ / ______ (MM/DD/YYYY)
Gender: Male __ Female __
Social Security #:
Address:
City: ______________________________ State: ______ Zip:
Phone #:
(please include a copy of the front & back of the insurance card)
BILL:
Medicare ___ Medi-Cal ___ Insurance ___
Policy Name Holder (if not patient)
___________________________
Patient relationship to policy holder
Self: ___ Spouse: ___ Child: ___ Other: _______
Policy holder Date of Birth: ___ / ___ / ______ (MM/DD/YYYY)
Social Security #
Insurance Company Name:
Billing Address:
City, State, Zip:
Insurance ID:
Employer/Company Name:
Group #:
Authorization (Patient Signature):
X
ABN: I request and authorize KPC Biotech Molecular Laboratory to perform the designated test(s) on the DNA sample provided by me. My signature above constitutes my acknowledgement that I have been informed of the benefits and limitations of this testing which have been explained to my satisfaction by a qualified health professional. I also understand that reference/testing lab reserves the right to provide de-identified information of a statistical nature to accrediting agencies and reserves the right to use such anonymous information.
Assignment of Benefits: I hereby authorize the entity to bill my insurance company and receive payment from them on my behalf. I acknowledge, however, that I am responsible for payment of my account and any and all charges associated with it’s collection. I hereby authorize the entity, or their designee, to appeal my health plan on my behalf to provide the actions and information necessary to overturn the denial or receive reimbursement for the underpaid claim. This authorization shall remain valid until the charges for the orders on this form are paid in full.
Collection Date: ____ / ____ / ______ Time:
Source: Urine (voided)
Collector Initial:
ORDERING CLINICIAN / LABORATORY INFORMATION
ICD-10 CODES
SPECIMEN TYPES: Urine (voided)
COMMON SIGNS & SYMPTOMS: Consider if patient has high risk heterosexual behavior, high risk homosexual behavior, or suspected
exposure to a sexually transmitted infection. Z11.3, Z20.2, Z72.51, Z72.52
Facility/Practice Name:
Office Contact Name:
Office Phone Number:
Ordering Physician:
NPI #:
ICD-10 Codes:
KCDx-102324
Sexually Transmitted Infection
Physician Signature:
X
My Signature, as attending physician, serves as authorization of this test as medically necessary.